Randomised controlled trial comparing hospital at home care with inpatient hospital care. II: cost minimisation analysis

OBJECTIVES: To examine the cost of providing hospital at home in place of some forms of inpatient hospital care. DESIGN: Cost minimisation study within a randomised controlled trial. SETTING: District general hospital and catchment area of neighbouring community trust. SUBJECTS: Patients recovering from hip replacement (n=86), knee replacement (n=86), and hysterectomy (n=238); elderly medical patients (n=96); and patients with chronic obstructive airways disease (n=32). INTERVENTIONS: Hospital at home or inpatient hospital care. MAIN OUTCOME MEASURES: Cost of hospital at home scheme to health service, to general practitioners, and to patients and their families compared with hospital care. RESULTS: No difference was detected in total healthcare costs between hospital at home and hospital care for patients recovering from a hip or knee replacement, or elderly medical patients. Hospital at home significantly increased healthcare costs for patients recovering from a hysterectomy (ratio of geometrical means 1.15, 95% confidence interval 1.04 to 1.29, P=0.009) and for those with chronic obstructive airways disease (Mann-Whitney U test, P=0.01). Hospital at home significantly increased general practitioners' costs for elderly medical patients (Mann-Whitney U test, P<0.01) and for those with chronic obstructive airways disease (P=0.02). Patient and carer expenditure made up a small proportion of total costs. CONCLUSION: Hospital at home care did not reduce total healthcare costs for the conditions studied in this trial, and costs were significantly increased for patients recovering from a hysterectomy and those with chronic obstructive airways disease. There was some evidence that costs were shifted to primary care for elderly medical patients and those with chronic obstructive airways disease.     

The effectiveness of systematic stroke care

A coordinated, multidisciplinary approach had been applied to enhance the effectiveness of stroke care with varying enthusiasm; however, the effectiveness of this kind of stroke treatment model was noted in many studies. This study was designed to measure the effectiveness of systematic stroke management on the physical-functional outcome in terms of Activities of Daily Living (ADLs) scores. The higher the ADLs score, the higher the degree of physical disability, i.e., the higher the degree of dependence. Eighty-six stroke patients from the Department of Neurology in a medical center, and 88 stroke patients from the Department of Medicine in a local hospital were followed from the admission day to the discharged date. The effectiveness of stroke care in each hospital was measured by the comparisons between ADLs scores at discharge and ADLs scores at admission. Two-sample tests show that demographic characteristics, length of stay, average time elapsed since the occurrent stroke, number of families in caregiving, and ADLs scores at admission and at discharge did not differ much between these two groups. The improved ADLs scores for stroke patients treated in the Department of Neurology of the medical center were changed from the 14.1 +/- 4.9 at admission to 12.1 +/- 5.2 at discharge, and the changes of ADLs scores for patients treated in the Department of Medicine of the regional hospital was from 12.8 +/- 5.1 to 12.3 +/- 5.5 according to the degree of improvement. The significant finding was that the degree of improvement of ADLs scores for CVA patients from the medical center was significant (Wilcoxon Matched-Pairs Signed-Ranks Test, Z = -2.8, p < 0.01). Moreover, the degree of improvement of ADLs scores strongly differed between these two groups (Repeated measures of two-way ANOVA, F = 6.0, p < 0.05). The information presented here informs us that degree of physical-functional status of stroke patients should be improved because of the systematic stroke management.     

Transitional care: hospital to home

Contemporary acute hospital care of older adults must include special attention to the transitional, or peridischarge, phase of hospitalization. This article reviews the evidence from outcomes data and economic factors that demonstrate that precise transitional planning is a critical element in the care of older hospitalized adults. Some of the promising initiatives being explored around the country are reviewed.     

Effectiveness of home care programmes for patients with incurable cancer on their quality of life and time spent in hospital: systematic review

OBJECTIVE: To investigate whether for patients with incurable cancer comprehensive home care programmes are more effective than standard care in maintaining the patients' quality of life and reducing their "readmission time" (percentage of days spent in hospital from start of care till death). DESIGN: Systematic review. METHODS: A computer aided search was conducted using the databases of Medline, Embase, CancerLit, and PsychLit. The search for studies and the assessment of the methodological quality of the relevant studies were performed by two investigators, blinded from each other. Prospective, controlled studies investigating the effects of a home care intervention programme on patients' quality of life or on readmission time were included in the analyses. RESULTS: Only 9 prospective controlled studies were found; eight were performed in the United States and 1 in the United Kingdom. Their methodological quality was judged to be moderate (median rating 62 on a 100 point scale). None of the studies showed a negative influence of home care interventions on quality of life. A significantly positive influence on the outcome measures was seen in 2 out of the 5 studies measuring patients' satisfaction with care, in 3/7 studies measuring physical dimensions of quality of life, in 1/6 studies measuring psychosocial dimensions, and in 2/5 studies measuring readmission time. The incorporation of team members' visits to patients at home or regular multidisciplinary team meetings into the intervention programme seemed to be related to positive results. CONCLUSIONS: The effectiveness of comprehensive home care programmes remains unclear. Given the enormity of the problems faced by society in caring for patients with terminal cancer, further research is urgently needed.     

The effectiveness of acupuncture in treating acute dental pain: a systematic review

OBJECTIVE: Acupuncture is frequently advocated as an effective treatment of dental pain. The question whether or not it is effective for this indication remains controversial. The aim of this systematic review therefore was to assess the effectiveness of acupuncture in dental pain. DATA SOURCES: Four electronic databases were searched: Medline, Embase, CISCOM, and the Cochrane Library. Only controlled trials were included in this review. DATA EXTRACTION: Information was extracted from included studies and entered on standard forms independently by both authors. Methodological quality was assessed using the Jadad score. MAIN RESULTS: 16 such studies were located. The majority of these trials imply that acupuncture is effective in dental analgesia. However, important questions remain unanswered. CONCLUSION: It is concluded that acupuncture can alleviate dental pain and that future investigations should define the optimal acupuncture technique and its relative efficacy compared with conventional methods of analgesia.     

The effectiveness of surgery for stress incontinence in women: a systematic review

OBJECTIVE: To determine the methodological quality of studies evaluating surgery for stress incontinence, the effectiveness of different procedures and the frequency of complications associated with each procedure. MATERIALS AND METHODS: Eleven randomized controlled trials, 20 non-randomized trials/prospective cohort studies and 45 retrospective cohort studies were reviewed systematically. RESULTS: The methodological quality of the 31 prospective studies was generally poor. The considerable variation in inclusion criteria, surgical management and assessment of outcome precluded any statistical meta-analysis. Evidence as to the effectiveness of surgery for stress incontinence is weak; therefore, any conclusions are speculative. It appears that colposuspension may be more effective and the effect more long-lasting than that following anterior colporrhaphy and needle suspension. There is little information on the value of sling procedures. Comparisons of different ways of performing each procedure show no significant differences in outcome but this may reflect the methodological weaknesses of the studies. Valid and reliable data on the frequency of complications following surgery are lacking so the safety of the procedures is unclear. Repeat operations to correct stress incontinence are less successful than first procedures but this finding may be subject to confounding. CONCLUSIONS: There is an urgent need for some large, rigorous, prospective studies of high quality. Until such studies have been completed, recommendations as to the best clinical practice cannot be based on scientific evidence. Studies need to define cases according to widely accepted criteria, including standard measures of the severity of stress incontinence, and surgical terminology for the procedures performed needs to be standardized and outcomes need to be clearly defined, valid and reliable, not confined to short-term assessment and include patients' views along with the surgeon's assessments.     

The effectiveness and safety of vaccines against human anthrax: a systematic review

We report on the results of a systematic review of existing controlled clinical trials undertaken to assess the effectiveness and safety of vaccines against human anthrax in relation to disease incidence and side-effects. Two articles retrieved by electronic and hand search fulfilling some of the inclusion criteria underwent a quality assessment by a group of reviewers. Data synthesized from the two trials showed that estimates of overall effectiveness and safety favour treatment (overall odds ratio 0.16; 95% confidence interval 0.07-0.34). The route of inoculation appears to make little difference to the effectiveness of the vaccines; however, one study shows that the incidence and severity of side-effects are significantly higher with the killed vaccine than with the alum-based placebo (overall odds ratio 0.16; 95% confidence interval 2.38-27.17).     

Impact of home care on hospital days: a meta analysis

OBJECTIVE: To examine the impact of home care on hospital days. DATA SOURCES: Search of automated databases covering 1964-1994 using the key words "home care," "hospice," and "healthcare for the elderly." Home care literature review references also were inspected for additional citations. STUDY SELECTION: Of 412 articles that examined impact on hospital use/cost, those dealing with generic home care that reported hospital admissions/cost and used a comparison group receiving customary care were selected (N = 20). STUDY DESIGN: A meta-analytic analysis used secondary data sources between 1967 and 1992. DATA EXTRACTION: Study characteristics that could have an impact on effect size (i.e., country of origin, study design, disease characteristics of study sample, and length of follow-up) were abstracted and coded to serve as independent variables. Available statistics on hospital days necessary to calculate an effect size were extracted. If necessary information was missing, the authors of the articles were contacted. METHODS: Effect sizes and homogeneity of variance measures were calculated using Dstat software, weighted for sample size. Overall effect sizes were compared by the study characteristics described above. PRINCIPAL FINDINGS: Effect sizes indicate a small to moderate positive impact of home care in reducing hospital days, ranging from 2.5 to 6 days (effect sizes of -.159 and -.379, respectively), depending on the inclusion of a large quasi-experimental study with a large treatment effect. When this outlier was removed from analysis, the effect size for studies that targeted terminally ill patients exclusively was homogeneous across study subcategories; however, the effect size of studies that targeted nonterminal patients was heterogeneous, indicating that unmeasured variables or interactions account for variability. CONCLUSION: Although effect sizes were small to moderate, the consistent pattern of reduced hospital days across a majority of studies suggests for the first time that home care has a significant impact on this costly outcome.     

The effectiveness of nursing care after discharge from hospital

Increasing pressures on health care services point to a growing role for post-discharge nursing care. Yet, the evidence concerning such aftercare services has been questioned. This article discusses a systematic review of research on the effectiveness of nursing care after discharge from hospital. The review shows that such care provides no additional benefits compared with usual care.     

Postpartum home visits: extending the continuum of care from hospital to home

Crucial maternal, newborn, and family healthcare needs arise during the early postpartum period, providing the opportunity for home care nurses to extend the continuum of care from hospital to home. This study identifies common early postpartum problems discovered on home health visits and describes the related interventions of home health nurses. Correlational analysis revealed that young mothers, first-time mothers, breastfeeding mothers, and single mothers are priority candidates for follow-up home care.     

Hospital at home or acute hospital care? A cost minimisation analysis

OBJECTIVE: To compare, from the viewpoints of the NHS and social services and of patients, the costs associated with early discharge to a hospital at home scheme and those associated with continued care in an acute hospital. DESIGN: Cost minimisation analysis. SETTING: Acute hospital wards and the community in the north of Bristol (population about 224 000). SUBJECTS: 241 hospitalised but medically stable elderly patients who fulfilled the criteria for early discharge to a hospital at home scheme and who consented to participate. MAIN OUTCOME MEASURES: Costs to the NHS, social services, and patients over the 3 months after randomisation. RESULTS: The mean cost for hospital at home patients over the 3 months was 2516 pounds, whereas that for hospital patients was 3292 pounds. Under all the assumptions used in the sensitivity analysis, the cost of hospital at home care was less than that of hospital care. Only when hospital costs were assumed to be less than 50% of those used in the initial analysis was the difference equivocal. CONCLUSIONS: The hospital at home scheme is less costly than care in the acute hospital. These results may be generalisable to schemes of similar size and scope, operating in a similar context of rising acute admissions.     

Better at home: a continuous health care program for patients with advanced chronic respiratory disease

The objective of this study was to analyze the effect of continuous health care on the frequency of readmissions of patients with advanced chronic respiratory disease. The study was prospective, enrolling 26 patients (16 with COPD, 7 with bronchiectasis and 3 with pachypleuritis) who had been admitted at least 3 times within the past year. The patients were assigned to 3 groups: group A was the ambulatory monitoring group, with 8 patients who were able to travel to the hospital for monthly outpatient checkups; group B was the ambulatory pulmonary rehabilitation group, with 10 patients who were able to travel to the hospital and who needed rebreathing training (one weekly group session); and group C was the home care group, with 8 patients who were unable to travel to the hospital and who received weekly or biweekly house calls. All patients had telephone contact with the program team. Mean lung function values for the whole population were FVC 40 (11)%, FEV1 23 (7)% of reference, PaO2 55 (7) and PaCO2 55 (10) mmHg. A significant decrease in number of admissions (79 versus 18, p < 0.0001) was observed in both the first and second halves of the year in all three treatment groups: A, 25 to 2; B, 28 to 8; and C, 26 to 8 (p < 0.001). The reduction in health care costs over the previous year's expenditure was calculated to be 22,751,402 pesetas. We conclude that specialized health care that is continuous and personalized reduces the number of hospital readmissions of patients with advanced chronic respiratory disease. Moreover, the overall cost of care, without the need to make house calls to all patients.     

Characteristics of bedridden elderly people living at home and in a hospital

We compared bedridden elderly people living at home to others who were hospital inpatients. Questionnaires regarding medical status and care were returned by 85 of 116 people caring for a bedridden elderly person at home in Obu city, Aichi prefecture and by 62 of 64 nurses and family members caring for bedridden inpatients at Chubu National hospital. All subjects were at least 65 years old. The median age in both groups was 81 years, neither age distribution nor female sex predominance differed between both groups. The percentage of subjects with only one underlying disease was 62.5% among those living at home and 64.4% among inpatients. In both groups the most common disease was cerebrovascular disease (42.5% among those at home and 39.0% among inpatients), followed by dementia (31.3%), infirmity of old age (17.5%) and bone fracture (13.8%) among those at home, and by bone fracture (27.1%), dementia (20.3%) and infirmity of old age (16.9%) among inpatients. The median durations of bedridden status were 2 years and 3 months among those at home and 3 months among inpatients. The proportion of subjects bedridden for less than 6 months was greater among inpatients (p < 0.0001). The percentage who needed medical treatment was 60.0% among those at home and 67.7% among inpatients. The most common conditions for which drugs were taken were hypertension, dementia, chronic cerebrovascular dysfunction, and osteoporosis. Among inpatients, 54.8% were ambulatory before admission, 24.2% were almost completely bedridden, and 17.7% were completely bedridden. The most common cause rending the patients bedridden was infection (usually pneumonia). The degree of disability did not differ between groups. Decubitus ulcers were present in 25.9% of those at home and 17.7% of inpatients.     

Special care for newborns at a community hospital: a 5-year experience

Anthralin has been a consistently effective drug for the treatment of psoriasis for more than 80 years, but has not enjoyed common use in the United States because of the unwanted side effects of irritation and staining. New treatment methods such as short-contact therapy and innovative vehicle formulations minimizing these problems have allowed anthralin once again to be used effectively in psoriatic treatment programs. We review these newer adaptations and suggest that the enduring modality deserves an important place in the topical armamentarium.